Chamberlain College of Nursing NR 224 Exam 2 Study Outline

NR 224 Exam 2 Study Outline The following is a list of concepts for you to understand to be successful on Exam 2 Skin  Pressure ulcers o Stages – describe, identify Category/Stage I: Nonblanchable Redness. Intact skin presents with nonblanchable redness of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. It may indicate “at risk” people Category/Stage II: Partial-Thickness. Partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or serosanguinous-filled blister. It presents as a shiny or dry shallow ulcer without slough or bruising. The presence of bruising indicates deep tissue injury. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation. Category/Stage III: Full-Thickness Skin Loss. In full-thickness tissue loss subcutaneous fat may be visible; but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not visible or directly palpable Category/Stage IV: Full-Thickness Tissue Loss. In full-thickness tissue loss with exposed bone, tendon, or muscle, subcutaneous fat may be visible; but bone, tendon, and muscle are exposed. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable Unstageable/Unclassified: Full-Thickness Skin or Tissue Loss—Depth Unknown.Full-thickness tissue loss in which actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed is unstageable. Until enough slough and/or eschar are removed to expose the base of a wound, the true depth cannot be determined; but it will be either a category/stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the natural (biological) cover of the body” and should not be removed Suspected Deep-Tissue Injury—Depth Unknown. Suspected deep-tissue injury is a purple or maroon localized area of discolored intact skin or a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared 1188to adjacent tissue. Deeptissue injury may be difficult to detect in individuals with dark skin tones. It may begin as a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. o Prevention – specific interventions Quick Guide to Pressure Ulcer PreventionRisk Factor Nursing Interventions Decreased sensory perception Provide pressure-redistribution surface. Be sure to include protection for pressure points from medical devices such as oxygen tubing, feeding tubes, and casts (Black et al., 2015   ; Fletcher, 2012). Moisture Following each incontinent episode, clean area with no-rinse perineal cleaner and protect skin with moisture-barrier ointment (Rolstad et al., 2016   ). Keep skin dry and free of maceration (Gray et al., 2011   ; Colwell et al., 2011   ). Turn patient off of at-risk areas often. Friction and shear Reposition patient using drawsheet or a transfer board surface. Provide trapeze to facilitate movement in bed. Position patient at a 30-degree lateral turn and limit head elevation to 30 degrees (see Figure 48-15). Decreased activity/mobility Establish and post individualized turning schedule. Poor nutrition Provide adequate nutritional and fluid intake; help with intake as necessary. Consult dietitian for nutritional assessment and recommended nutrients